Assessment of Knowledge, Attitudes, and Practice of Community Pharmacists Regarding Weight Reduction Agents and Supplements in Aseer Region, Saudi Arabia

Introduction

Being overweight and obesity are defined as excessive fat accumulation that may affect normal daily activities.¹ Obesity is highly acknowledged as epidemic and a public health threat. Obesity is described as a disease nowadays, and obese people are at high risk of serious secondary diseases such as hypertension, diabetes mellitus type 2, dyslipidemia, metabolic syndrome, cardiovascular diseases, and certain cancers.^1–5

The obesity prevalence in developing and developed countries is steadily increasing due to lack of exercise (sedentary lifestyle) and the presence of easily accessible processed fast food almost everywhere. It has become the fifth leading cause of mortality worldwide.^6,7 In Saudi Arabia, multiple recent studies have shown that the increase in the prevalence of overweight and obese people is related to modern lifestyles involving increased daily animal consumption instead of the consumption of organic food, fruits, and vegetables.^8,9

Dietary supplements are products containing one or more dietary ingredients such as vitamins, extracts, and herbs. They are intended to supplement a normal diet by adding certain nutritional value.^10,11 The clinical effects of most of these supplements have not been sufficiently evaluated in double-blinded, randomized clinical trials. Although small preclinical studies may report that dietary supplements and over-the-counter (OTC) weight reduction products reduce weight through various mechanisms of action, the vast majority of these products lack sufficient evidence when considering the whole picture, including the purity grade, effects on other health-related conditions, food–drug interactions, and potential side effects.^12,13

Self-medication in Saudi Arabia is a common practice. Several studies show that OTC products and herbal remedies are widely used to treat diabetes, epilepsy, obesity, and to manage pain episodes.^14–17 Community pharmacies are considered to be important providers of weight reduction products and supplements as they provide easy access to healthcare providers with zero waiting time. This situation has made dietary supplements and OTC weight reduction products easily accessible to the general population.^17–20

The unlicensed weight reducing products have been an alert for long time in Saudi Arabia. The Saudi Drug and Food Authority (SFDA) keeps fighting the presence of such unlicensed and adulterated products in Saudi market. Most of these products contain high percentage of sibutramine (a restricted pharmaceutical agent) which being sold by unlicensed centers and vendors.²¹

This study assessed the knowledge, attitudes, and practice of community pharmacists regarding prescribing complementary supplements and/or non-prescription medications to overweight and obese patients.

Materials and Methods

Study Design

This is a cross-sectional questionnaire-based self-administrative study that was conducted across community pharmacies in Aseer region.

Sample Size and Sampling Technique

The questionnaire was randomly distributed to 90 community pharmacies in six major cities in Aseer region (Abha, Khamis Mushait, Mahayel, Sarat Abeeda, Ahad-Rufaida, and Bishah). The number of registered community pharmacists in Aseer region who were eligible to answer the study’s survey was 747 pharmacists.²¹ Using the sample size calculation formula, the number of participants was 224 with 95% confidence interval and 5% margin of error.

Where; = sample size, = statistic for a level of confidence (Z=1.96 is selected many literatures to give a good power in estimation the sample size), = expected prevalence or proportion.

Out of 221 pharmacists, 191 completed the survey (86.4% response rate). The questionnaire was written in English and handed to the pharmacist(s) in each pharmacy by a Doctor of Pharmacy (PharmD) interns (data collectors). The pharmacists were approached during daytime business hours. The pharmacists were asked to voluntarily participate in the study and given enough time to complete the survey. The investigators explained the objectives of the study to the pharmacists and assured them that their individual-level data regarding their experience, knowledge, and attitudes would neither be published nor passed on to anyone else. The data collection took place over 5 weeks between 25/03/2019 and 25/05/2019.

The risk of bias was diminished by the random selection of pharmacies and the processes to ensure participant anonymity (their identification was kept confidential, private data were not asked for, and responses were blindly pooled after ensuring questionnaire completeness).

Questionnaire

No previous studies were found to assess the knowledge, attitudes, and practice of community pharmacists towards prescribing of weight reducing products. Therefore, a panel of three academics and a family medicine consultant developed the questionnaire and the validation process included a pilot study involving four academics and ten community pharmacists. These initial data were not included in the results analysis. Then, the internal consistency (reliability) of the questionnaire was evaluated for 12 items (attitudes and practice questions) where the responses will be taken on 5-points Likert scale. From the 14 participants (pilot study), the standard deviation and variances were calculated for each item and overall for all items. The Chronbach alpha was calculated using the formula:

where K is the number of items (questions), is the overall variance, and is the sum of items variances. The internal consistency of the questionnaire was 0.787.

The questionnaire consisted of 26 questions on 4 domains; (Domain I: 8 questions related to demographics; Domain II: 6 questions on knowledge, with open and closed type questions; and Domains III and IV: 6 questions per domain related to the attitudes and practice of community pharmacists regarding prescribing weight reduction agents and supplements). The attitudes and practices were examined using a 5-point Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree) to assess the extent to which the pharmacists agree or disagree with the statements related to weight reduction drugs and herbal supplements.

Ethical Considerations

Ethical approval for this study was granted by the regional ethical committee in Aseer region (REC # 2018-06-23). All participants were asked for consent before starting the questionnaire.

Statistical Analysis

The questionnaires were reviewed for completeness and accuracy and the data were cleaned, coded, and then entered into SPSS version 20 (IBM Corp., Armonk, NY, USA). The sociodemographic data were analyzed using descriptive analysis. Categorical variables were reported as frequencies and percentages, and continuous variables were represented as means and standard deviations. The mean scores and standard deviations were calculated for each statement based on the 5-point Likert scale responses (indicating strongly agree, agree, neutral, disagree, and strongly disagree, respectively). Subsequently, the Likert scale responses were collapsed into three categories (agree, neutral, and disagree) and the pooled mean and standard deviation for agreement, neutral, and disagreement were assessed to present the responses more clearly.

Results

Respondents’ Sociodemographic Characteristics

Most of the respondents were males (98%) and most were 20–40 years old (173 out of 191 participants). Most of the participants were holding Bachelor of Pharmacy degree with less than 5-year experience (80% and 75.39%, respectively). The most commonly prescribed weight-reducing agent was green tea followed by oatmeal products and then ginseng. Sociodemographic characteristics are summarized in Table 1.

Table 1 Sociodemographic Characteristics of Participants

Respondents’ Knowledge Regarding Weight Reduction Agents

Table 2 shows the community pharmacists’ knowledge regarding the main weight reduction agents’ basic information. Almost 85% of the respondents did not know which weight reduction agents are US Food and Drug Administration-approved OTC products. The highest percentage of correct answers was for the statement regarding whether metformin is prescribed as an OTC weight reduction agent. Regarding the other knowledge questions, more than 50% of the participants provided incorrect answers.

Table 2 Community Pharmacists’ Knowledge About Main Weight Reduction Products

Respondents’ Attitudes Regarding Weight Reduction Agent Use

More than half of the participants believed that weight reduction agents are safe and effective but may not show true improvement in obese patients. However, 64.91% of the participants would limit weight reduction agents to obese patients who could not reduce their weight through exercise and diet. Most of the participants (84.81%) agreed that community pharmacists should advise patients regarding the best way to reduce their weight. More than 80% of the pharmacists agreed that knowledge and continuous education regarding weight reduction products are crucial both for community pharmacists and patients (Table 3).

Table 3 Community Pharmacists’ Attitudes Regarding Prescribing Weight Reduction Products

Participants’ Responses About Weight Reduction Product Prescribing Practices

Seventy-five percent of the participants regularly dispense weight reduction products without prescription. Furthermore, more than two-thirds of the participants think that the dispensed weight reduction products show efficacy regarding weight reduction. Moreover, more than 80% of the participants agreed that it is very important to counsel patients regarding dispensed weight loss products, and more than 80% also agreed that pharmacists should regularly discuss weight reduction products with other healthcare professionals. Table 4 summarizes the participants’ responses regarding prescribing weight reduction products.

Table 4 Community Pharmacists’ Responses Regarding Prescribing Weight Reduction Products

Discussion

To the best of our knowledge, this study is the first study in Saudi Arabia to assess the knowledge and attitudes of community pharmacists regarding weight reduction products. This study shows an enormous lack of knowledge among community pharmacists in Aseer region regarding weight reduction products and supplements. These results concur with the results of a study of community pharmacists in Australia, in which the participants were not able to identify the adverse effects and drug interactions of commonly used weight reduction products (green tea, chromium, and garcinia).²² These findings could be due to the lack of continuous education for community pharmacists. Furthermore, community pharmacists should be aware of the herbal drug interactions when they prescribe/provide advice regarding any weight reduction agents, especially for patients with concomitant chronic diseases such as hypertension and diabetes. Another study was conducted in Eastern region of Saudi Arabia showed similar results were the green tea was the most commonly used weight-reducing agent.²³

However, the participating pharmacists had positive attitudes toward the safety and efficacy of weight reduction products. This is going along with other studies that exhibited positive attitudes of community pharmacists towards using herbal remedies and nutraceutical products by Saudi and Kuwaiti populations.^21,24 Although community pharmacists in western countries were able to participate effectively and efficiently in weight management,^25–27 community pharmacists in the Middle East may not be able to provide the same service for obese patients due to many reasons such as the lack of trust in community pharmacists and barriers hindering obesity counseling.²⁸ In this study, pharmacists believed that patient counseling regarding weight reduction products is very important. Moreover, pharmacists believed that they should discuss the safety and efficacy of the products with other healthcare providers to update their knowledge and improve public health.

This was a cross-sectional study in Aseer region, Saudi Arabia. Even though the response rate to the survey was excellent (88%) and a large number of pharmacists (191) participated in the study, the generalization of the results to community pharmacists in other areas of Saudi Arabia is unclear, and more studies should be conducted in larger and more population-dense regions. In addition, we recommend that pharmacists should undergo continuous education and training to be able to provide their patients with accurate and optimal care.

Conclusion

This study showed that most of the respondents believe that increasing their knowledge regarding weight reduction products and having enough time to counsel the patients is important to improve the overall public health outcomes. However, the lack of basic knowledge regarding weight reduction products was noticeable; therefore, conducting more educational seminars and workshops is crucial to ensure basic knowledge among community pharmacists. Community pharmacists exhibited positive attitudes when it comes to the safety of weight reducing products. However, dispensing weight reducing products should be minimal and under mutual supervision of endocrinologists and pharmacists. The patient counseling is an important measure that should be taken into consideration to ensure appropriateness of medication use and patient safety. Moreover, the regulatory authorities should keep an eye on the provision of drugs and herbal products for obese patients without medical prescriptions.